15.9 Effectiveness of smokefree legislation in reducing exposure to tobacco toxins and changing smoking behaviours

Several meta-analyses of the impact of smokefree legislation have been published over the past 10 years concluding that such bans reduce exposure to tobacco toxins,1,2 reduce respiratory symptoms in workers1,2 and reduce the amount smoked among continuing smokers.1,3,4 There is also strong evidence1,4 that such bans encourage smokers to quit and to remain abstinent,1 and reduce social inequalities in secondhand smoke (SHS) exposure at work1

The most comprehensive and rigorous of these is the report of the International Agency for Research on Cancer, which systematically reviewed evidence on the effects of smokefree legislation and found strong to conclusive evidence in 11 of the 11 areas it studied. Results are summarised in Table 15.9.1.

Numerous additional studies and another major review2 have been published since release of the International Agency for Research on Cancer report, and evidence from these is summarised below.

The implementation of widespread bans on smoking have also been followed by reductions in hospital admissions for smoking-related diseases1,5 (see Chapter 15, Section 15.10 for further details).

Table 15.9.1
Evaluation of the weight of evidence for the effectiveness of smokefree legislation

 

Sufficient evidence

Strong evidence

Limited evidence

Evidence of no effect

Inadequate or no evidence

Smokefree policies do not cause a decline in the business activities of the restaurant and bar industry (Ch 4)

X

 

 

 

 

Implementation of smokefree policies leads to a substantial decline in exposure to SHS (Ch 6)

X

 

 

 

 

Implementation of smokefree legislation reduces social inequalities in SHS exposure at work (Ch 6)

 

X

 

 

 

Implementation of smokefree legislation causes a decline in heart disease morbidity (Ch 6)

 

X

 

 

 

Implementation of smokefree legislation decreases respiratory symptoms in workers (Ch 6)

X

 

 

 

 

Smokefree workplaces lead to reduced cigarette consumption among continuing smokers (Ch 7)

X

 

 

 

 

Smokefree workplaces lead to increased successful cessation among smokers (Ch 7)

 

X

 

 

 

Smokefree homes policies reduce tobacco use among youth (Ch 7)

 

X

 

 

 

Smokefree home policies reduce exposure to children to SHS (Ch 8)

X

 

 

 

 

Smokefree home policies reduce adult smoking (Ch 8)

X

 

 

 

 

Smokefree homes policies reduce youth smoking (Ch 8)

 

X

 

 

 

Source: International Agency for Research on Cancer 2009 1 refer to table p260.

15.9.1 Effects on employees in affected industries

Complete bans on smoking effectively eliminate exposure of employees to SHS, dramatically reducing employee biomarkers of exposure1,2 and almost eliminating reports of sensory symptoms associated with SHS.2,6–11

A number of studies in several different jurisdictions show reduced levels of cotinine (a marker of SHS exposure) among non-smoking staff and patrons after the implementation of smoking bans in pubs and clubs.7,9,12–16 Hospitality workers experience a greater reduction in exposure to SHS compared to the general population. Bar workers also experience a decrease in respiratory illness symptoms following the implementation of smokefree laws.13,17,18

A longitudinal study of the health of bar workers after the introduction of smokefree legislation in Scotland found bar workers reported significantly fewer respiratory and sensory symptoms one year after their working environment became smokefree. These improvements were seen in both non-smokers and smokers, and indicate that smokefree working environments may have potentially important benefits even for smokers.11 At one year follow-up, the percentage of bar workers reporting any respiratory symptoms fell from 69% to 57%, and for sensory symptoms, from 75% to 64% following reductions in exposure. For non-smokers, the reductions in reported symptoms were significant for phlegm production (32% to 14%) and red/irritated eyes (44% to 18%).11

There remains some debate about the impact of smokefree legislation on the smoking behaviour of the public and hospitality workers. While the focus of these regulatory measures is to protect public health, and particularly employee health, by reducing exposure to SHS, some studies have reported a reduction in smoking prevalence and consumption while others have found no evidence of such an effect.

A study examining the effects of smoking bans in Spain in all enclosed workplaces except hospitality venues—where only partial bans were implemented— reported 5% of Spanish hospitality workers surveyed had quit smoking and the number of cigarettes smoked among remaining smokers had reduced by 9%. The proportion of workers with a high nicotine dependence was also reduced by half after the ban (19.5% vs. 9.7%).19

15.9.2 Effects on population exposure to secondhand smoke

Smokefree legislation leads to reductions in population exposure to SHS.2,1 In Spain, the overall prevalence of exposure to environmental tobacco smoke decreased from 49.5% in 2005 to 37.9% in 2007 (22% reduction) following implementation of smokefree laws (although only partial restrictions were implemented in bars and restaurants). The greatest reduction in prevalence of SHS exposure was in workplaces (from 25.8% to 11%, a decrease of 58.8%). Smaller reductions occurred in the home (from 29.5% to 21.4%, a decrease of 27%) and in recreation venues (from 37.4% to 31.8%, a decrease of 8%).20 In New Zealand, exposure to SHS in the workplace decreased significantly from about 20% in 2003 to 8% in 2006.21 Air quality improved greatly in hospitality venues. Reported SHS exposure in homes also reduced significantly. A very large-scale US study published at the end of 2011 examining the relationship between clean air legislation and smoking policies in the home found that those living in counties with strong clean indoor air laws was associated with large increases in voluntary smokefree-home policies both in the homes with and without smokers. These results support the hypothesis of norm spreading of clean indoor air laws.22

15.9.2.1 Effects on children's exposure to secondhand smoke

Smokefree environments have generally been followed by reduction in children's overall exposure to SHS. The Cochrane Collaboration Review published in 2010 examined the results of 15 studies that measured exposure to SHS in the home (Abrams 2006; Akhtar 2007; Biener 2007; Brownson 1995; Fong 2006; Galán 2007; Gilpin 2002; Hahn 2006; Haw 2007; Hyland 2009; Jiménez-Ruiz 2008; Larsson 2008; Palmersheim 2006; Pell 2008; Waa 2006). In general there was no change after the implementation of the ban though some studies reported positive findings. Fong 2006 reported a significant reduction in homes where smoking was allowed and Gilpin 2002 indicated that the percentage of Californian adults reporting smokefree homes increased one year post ban. Similarly Waa 2006 reported reduced exposure in New Zealand. In two studies where home smoking was assessed, there was no change (Galán 2007 & Biener 2007). Galán 2007 showed a drop in smoking at work in compliance with the ban in Spain, but not at home. Similarly Biener 2007, in a Boston study, showed no reduction in home smoking rates (p8).

Research since publication of the Cochrane Collaboration review has continued to find evidence of reductions in children's exposure to SHS. A US study found that children and adolescents living in non-smoking homes in counties with smokefree public place laws had lower levels of cotinine in their blood than those in counties with no such laws.23 Following implementation of smokefree legislation in Italy, a study by Pellegrini et al demonstrated a significant trend towards lower exposure to SHS among young Italian adolescents aged 10–16 years.24

In response to concerns regarding potential displacement of smoking into the home following smokefree legislation, several studies assessed changes in SHS exposure among non-smoking children following legislative smoking bans. Studies of the impact of smokefree legislation in various parts of the UK reported a decline in children's exposure to SHS.25,26 In Wales, reported SHS exposure in public places (cafés, restaurants, buses, trains and indoor leisure facilities) fell significantly. However the home remained the main source of children's SHS exposure and did not change significantly post legislation.25 Following the implementation of smokefree legislation in Scotland, there was an increase in the proportion of children reporting a complete ban on smoking in their household.27 A similar pattern was reported in Queensland following implementation of new smokefree laws in 2006.28 Data from Hong Kong, however, found that the prevalence of exposure to SHS at home and outside the home both increased among primary school students in Hong Kong post legislation. Parental smoking rates were similar before and after the legislation.29

15.9.3 Effectiveness in prompting cessation

Smoking bans have shown to be helpful to smokers who are trying to quit by encouraging more quit attempts30 and increasing the chances of a successful quit attempt.3133 In a 2002 review of 26 studies on the effects of smokefree workplaces in the US, Australia, Canada and Germany, totally smokefree workplaces were associated with reductions in prevalence of smoking of 3.8%, and 3.1 fewer cigarettes smoked per day per continuing smoker.4 Additionally, smokers who are 'socially cued' to smoke in places such as bars may be more likely to give up smoking when comprehensive bans are introduced.34,35

Studies from Australia, New Zealand and Hong Kong found little evidence of a change in smoking cessation behaviour apart from an increase in calls to the Quitline in New Zealand and Hong Kong.36,21,37 Research by the Queensland Government in 2006, however, suggested that smokefree laws can act as a trigger for renewed quit attempts. More than one in five smokers (22%) reported they had attempted to quit following the introduction of new smokefree laws. This equated to an estimated 123,000 Queenslanders who had attempted to quit. About 2% of smokers reported they had successfully quit as a result of the new laws: an estimated 14,000 new ex-smokers. More than a quarter of ex-smokers (27%) reported that the new tobacco laws had helped them to not resume smoking.38

A systematic review published in 2010 examined the evidence of effectiveness of smokefree policies in reducing tobacco use between 1976 and 2005. The review concluded that the median absolute change was an increase in cessation of 6.4 percentage points. The studies examined provided sufficient evidence that smokefree laws reduce tobacco use among workers when implemented in worksites or by communities.39

Two studies reported an increase in the rate of smoking cessation in the three-month period immediately prior to smokefree legislation in Scotland.40,41 An examination of changes in sales of over-the-counter nicotine replacement therapy during the implementation of the legislation also suggest an increase in smoking cessation behaviour in the period immediately before the introduction of smokefree legislation, but this was not sustained beyond the first few months of the post-legislation period.41

A US study in Kentucky by Hahn et al reported significant reductions in smoking prevalence in communities with smokefree laws compared to control communities, resulting in 16,500 fewer smokers.42 Other research by Hahn et al suggested that smokefree laws may have a delayed effect on cessation among adults; that is, the longer a smokefree law is in effect, the more likely adults will attempt to quit smoking and become former smokers.43

The implementation of workplace smoking bans was followed by a decrease in smoking prevalence in The Netherlands but there was no further reduction in prevalence associated with a hospitality industry smoking ban.44 Both bans, especially the workplace ban, were followed by an increase in quit attempts and successful quit attempts. The workplace ban had a larger effect on successful quitting among higher educated than on lower educated respondents. The hospitality industry ban had a larger effect on quit attempts among frequent bar visitors than on non-bar visitors.44

A British study reported that a smoking ban in Bury, England, did not have a substantial impact on smoking prevalence but had an impact on consumption, reducing the proportion of heavy smokers. The baseline survey found that the standardised prevalence of smoking before the ban was 22.4% and after the ban was 22.6%. The proportion of smokers reporting that on average they smoked 20 cigarettes a day or more fell from 27.6% to 21.8%.45

The 2009 expert report of the scientific committee of the International Agency for Research on Cancer concluded that the evidence was strong but not 'sufficient' that smokefree workplaces lead to increased successful cessation among smokers.1 The Cochrane Collaboration review published in the following year concluded:

  • 'The effect of smoking bans on smoking prevalence was inconclusive with smoking prevalence declining slightly in most of the population based studies, particularly amongst working men but remaining unchanged or not adequately assessed in the studies of workplaces. There was inconsistent evidence of a reduction in cigarette consumption, but in studies where declines in prevalence were recorded, consumption levels also fell. Whilst several country-based studies did show improvements in smoking trends, the question of active smoking merits further investigation' (p11).2

15.9.4 Effectiveness in reducing youth smoking

A number of studies have identified the positive impact of smokefree legislation on the initiation and prevalence of youth smoking.4648

Research from Massachusetts in the US shows that smokefree legislation has an impact on initiation of smoking among young people and the strength of smokefree restrictions in the legislation is a key factor influencing the uptake of smoking.46 Young people living in towns with a strong restaurant smoking regulation at baseline had significantly lower odds of progressing to established smoking compared with those living in towns with weak regulation. The observed association between strong restaurant smoking regulations and impeded progression to established smoking was entirely due to an effect on the transition from experimentation to established smoking. The study concluded that local smokefree restaurant laws can significantly lower youth smoking initiation by impeding the progression from cigarette experimentation to established smoking.46 Another US study found similar results—compared with students living in states with strict regulations, those living in states with no or minimal restrictions, particularly high school students, were more likely to be daily smokers.47

A 2011 Australian study confirms that adult-directed, population-based tobacco control policies such as smokefree legislation and increased prices of cigarettes, implemented as part of a well-funded comprehensive tobacco control program, can reduce adolescent smoking.48

15.9.5 Effects on low socio-economic status and Indigenous groups

As indicated in Table 15.9.1 above, in its systematic review the International Agency for Research on Cancer concluded that there is strong evidence that smokefree legislation leads to reductions in social inequalities in exposure to tobacco smoke.1 But what about the impact on subsequent rates and success in quitting?

A review of studies on the impact of various tobacco control policies among different socio-economic status (SES) groups found mixed results for workplace smoking bans.49 A subsequent study from The Netherlands also suggested that the introduction of workplace bans had a larger effect on successful quitting among higher-educated than on lower-educated respondents.44 However the same study found that restrictions on smoking in bars had a greater effect on subsequent quitting among people who attended bars than among those who did not. One study examining smoking behaviours among parents with young children suggested that smokefree legislation does not appear to widen health inequalities and may even help reduce them by encouraging quitting across SES groups.50

A US study reported that smokefree laws and tobacco price increases appear to benefit all socio-economic and race/ethnic groups equally in terms of reducing smoking participation and consumption.51

A study of 106 randomly selected bars in Scotland, England and Wales before and after the introduction of smoking restrictions found that prior to legislation, there was evidence that bars located in more deprived postcodes had higher concentrations of harmful particulate matter.52 In relation to health outcomes, reductions in hospital admissions for asthma associated with smoking bans were apparent among both preschool and school-age children. There were no significant interactions between hospital admissions for asthma and age group, sex, urban or rural residence, region, or quintile of SES.

The impact of smokefree legislation on Indigenous peoples is not well documented (see Chapter 8, Section 8.10.12). A study by Edwards et al examined the impact of the New Zealand Smokefree Environments Amendment Act on Indigenous Maori people in New Zealand. The study found that support for the legislation was strong among Maori and by 2006, support reached 90% for smokefree restaurants and 84% for smokefree bars. Maori stakeholders interviewed were mostly supportive of the way the legislation had been introduced. Reported exposure to SHS in workplaces decreased similarly in Maori and non-Maori with 27% of employed adult Maori reporting SHS exposure indoors at work n 2003 compared with only 9% in 2006. Exposure to SHS in the home declined, and may have decreased more, in Maori households containing one or more smokers. For example, the proportion of Maori children aged 14­­­–15 years reporting that smoking occurred in their home fell from 47% in 2001 to 37% in 2007. In common with other research studies, evidence for the effect on smoking prevalence was mixed. However Maori responded to the new law with increased calls to the national Quitline service.53

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